Foot and Ankle Flashcards
1
Q
Tibial external rotation with DF in closed chain resulting in injury with pain at the distal tibia and fibular is associated with what type of injury?
A
- syndesmotic injury; high ankle sprain
2
Q
closed chain eversion injury with pain on the medial ankle/foot is associated with what type of injury?
A
- eversion injury; medial ankle sprain
3
Q
What is a large difference with care/precautions following a syndesmotic injury (high ankle sprain) compared to a medial or lateral ankle sprain?
A
- more conservative WB to allow for healing of the syndesmosis
4
Q
What are the two subgroups/categories/phases conceptually for the CPG for lateral ankle sprains?
A
- Acute/protected motion phase
- Progressive loading/sensorimotor training phase
5
Q
What are the characteristics of the acute/protected motion phase?
A
Significant edema or pain
w/in ~ 72 hours of injury
limited weight bearing
evidence of overt gait deviations
6
Q
What are the characteristics of the progressive loading/sensorimotor training phase?
A
Primary concerns of functional instability
Generally more chronic presentation
7
Q
What are the two primary ligaments affected by a lateral ankle sprain, and which order are they affected in?
A
- ATFL first, then CFL
8
Q
What is the standard mechanism of injury for a lateral ankle sprain?
A
o Ankle/foot in plantar flexed position, followed by hypersupination at forefoot/midfoot
9
Q
Other than the ATFL and CFL, what structures can be affected by a lateral ankle sprain? (7)
A
- posterior TFL
- anterior deltoid ligament
- lateral subtalar ligament
- peroneal retinaculum
- extensor retinaculum
- peroneal tendons
- superficial peroneal nerve
10
Q
What are the main differential dx in the acute phase of lateral ankle sprain? (6)
A
Fractures Muscle strains Cuboid syndrome Syndesmosis Subtalar joint sprain Adjacent joint sprains
11
Q
What are the main differential dx in the post-acute phase of lateral ankle sprain? (6)
…there are a lot more than 6…but these are the first 6 that showed up in the slide
A
Chronic (functional) ankle instability Accessory ossicles Tarsal coalition Impingement (anterolateral or posterior) Osteochondral lesions Sinus Tarsi Syndrome
12
Q
What are the Ottawa Ankle Rules for a lateral ankle sprain?
A
Imaging needed if:
- unable to bear weight for more than 4 steps immediately after the injury or in the ED
- pain with palpation of:
• Malleolar zone or midfoot zone
• Posterior edge or tip of either malleolus
• Navicular
• Styloid px of 5th metatarsal
13
Q
Functional risk factors for lateral ankle sprain are generally related to what two things?
A
- general movement habits
- ability to correct in the face of a hypersupination load
14
Q
What 4 functional risk factors for lateral ankle sprain have level I evidence support?
A
- abnormal gait mechanics
- impaired postural stability
- impaired proprioception
- impaired NM reaction time
15
Q
What 3 functional risk factors for lateral ankle sprain have Level II evidence support?
A
- low aerobic fitness
- deficits in cutaneous sensation
- deficits in nerve conduction velocity
16
Q
What 2 functional risk factors for lateral ankle sprain have Level IV evidence support?
A
- low ankle eversion strength
- impaired balance test performance
17
Q
What 2 structural risk factors for lateral ankle sprain have Level I support?
A
- foot and ankle morphology
- specific ankle laxity (increased talar supination; talar tilt)
18
Q
What 6 structural risk factors for lateral ankle sprain have Level II support?
A
- limited ankle complex ROM
- other morphological characteristics
- general joint laxity
- limb dominance
- Female gender
- specific ankle complex laxity
19
Q
What 5 extrinsic risk factors for lateral ankle sprain have Level I support?
A
- Poor environmental conditions/playing surface
- Court or team-based activity or sport
- Use of ankle tape and or/brace (reduce)
- Use of foot orthoses (reduce)
- Warm up including stretching (reduce)
20
Q
What 5 extrinsic risk factors for lateral ankle sprain have Level II support?
A
- Level of competition or intensity
- Patient sex; effect on severity of injury
- Preventative efforts and patient education (reduce)
- Appropriate shoe type to playing conditions (reduce)
- Slower self-selected running speed
21
Q
What are 5 outcome measures that are appropriate during eval to assess function for lateral ankle sprain?
A
- Foot and Ankle Ability Measure (FAAM)
- LEFS
- Ankle Joint Functional Assessment Tool (AJFAT)
- Chronic Ankle Instability Scale (CAIS)
- Sports Ankle Rating Scale (SARS)
22
Q
What are 3 appropriate outcome measures designed to identify or grade severity with functional ankle instability? (FAI)
Which ones ID, vs grade severity, or both?
A
- Ankle Instability Instrument: ID and grade severity
- Cumberland Ankle Instability Tool: grade severity
- Functional Ankle Instability Questionnaire: ID
23
Q
What are the 6 characteristics of a Grade I lateral ankle sprain?
A
- No loss of function
- No ligamentous laxity
- Little or no hemorrhage
- No point tenderness
- Decreased total ankle motion of 5 degrees or less
- Swelling of 0.5 cm or less
24
Q
What are the 6 characteristics of a Grade II lateral ankle sprain?
A
- Some loss of function
- Positive anterior drawer test (ATFL involvement)
- Negative talar tilt test (no CFL involvement)
- Hemorrhaging
- Point tenderness
- Decreased total ankle motion > than 5* but < 10*
- Swelling > 0.5 cm but < 2.0 cm
25
What are the 6 characteristics of a Grade III lateral ankle sprain?
- Near total loss of function
- Positive anterior drawer and talar tilt tests
- Hemorrhaging
- Extreme point tenderness
- Decreased total ankle motion > 10*
- Swelling > 2.0 cm
26
How are Grade IIIA and IIIB lateral ankle sprains defined?
- By radiograph
o Grade IIIA: anterior drawer movement of 3 mm or less
o Grade IIIB: anterior drawer movement of > 3 mm
27
Describe the execution of an anterior drawer test.
- Medially rotate lower leg, hold foot/ankle in 20* plantar flexion and then pull to look for laxity
- Or, put pt supine on a table with their knee bent. Palpate talar head, the posteriorly push the tib/fib, feeling for movement
28
Describe the execution of the talar tilt test
- assess for laxity with rearfoot inversion
29
What are 3 considerations when measuring ankle DF ROM in open-chain?
- account for the DF axis of rotation being slightly externally rotated; will have to medially rotate the tibia if using cardinal planes
- Differentiate between gastroc/soleus restrictions, by measuring in prone in knee extension and ~ 45* flexion
- measure from the plantar surface of the fat pad, not the alignment of the 5th met
30
What are 4 balance assessments from the lateral ankle CPG?
- Balance Error Scoring System (BESS)
- Simple Balance Test (SBT)
- Star excursion balance test
- Y-balance test
31
Why do the Simple Balance Test?
- there is a relationship between a positive test result and likelihood for ankle sprains
32
Young women who have > ___ difference between LEs on the Y balance test are ____ more likely to experience a LE injury on the ____ side
Young women who have > 4 cm gross difference between sides are 2.5x more likely to experience a LE injury on the side that is “shorter”
33
What is a good activity level test for acute lateral ankle sprain?
What % of difference between sides is concerning and why?
- Lateral hop for distance
| - ~20% difference between sides is indicative of prolonged disability
34
What are 4 hop tests that can be used in the post-acute phase for a lateral ankle sprain to assess for activity/participation?
- figure of 8 hop test
- square hop test
- side hop test
- 6 meter crossover hop test
35
Is manual therapy appropriate for acute ankle sprain? What grade evidence?
- yes; grade B
| - multiple manual techniques are appropriate
36
What is the CPR for manual therapy for an acute ankle sprain? (4)
```
Navicular drop of 5 mm or >
Symptoms worse:
• In standing
• In the evening
Hypomobility of the distal TF joint
```
37
What are some appropriate manual techniques noted for lateral ankle sprain? (7)
- active mobilization (muscle energy)
- oscillatory graded procedures
- strain-counterstrain
- manual lymph drainage
- soft tissue mobilization
- joint mobs
- joint manipulations
38
What is the common goal for manual techniques with lateral ankle sprain?
- improving DF
39
What are 3 joint manipulations that would be appropriate for lateral ankle sprain?
- long axis traction; bring into DF and quickly pull
- fibular head manip; posteriorly directed w/ knee in full flx
- tarsal whip
40
Are joint manipulations appropriate for acute lateral ankle sprain?
- nah...not really
41
What are 4 appropriate exercises for acute rehab of lateral ankle sprain?
- AROM
- seated isometrics
- hip and trunk exercises
- arch lifts
42
What grade evidence supports exercise-based intervention for lateral ankle sprain rehab in the acute phase?
- Grade A. Do it.
43
In the post-acute phase of lateral ankle sprain recovery, what is the grade of evidence for support of exercise interventions?
- Grade D (conflicting)
44
Is WB therex recommended for rehab of lateral ankle sprain in the acute phase?
- NWB has support. WB as tolerated, likely, but doesn't have the same support as NWB in the literature.
45
Is it ok to reproduce symptoms during WB therex in the post-acute phase of rehab for lateral ankle sprain?
- in general, you want to avoid reproduction of symptoms during and after the therex
46
Does closed-chain therex have support for post-acute phase of rehab for lateral ankle sprain?
- yes, at the impairment level
47
What are appropriate exercises in the post-acute phase of lateral ankle sprain rehab? (4)
- squat, lunge, heel raise progressions
- trunk progressions
- arch control progression/integration
- calf stretch
48
What can be done to avoid plantar fascia stretching when trying to stretch the calf?
- wedge the head of the first met
49
What type of exercise is standard/appropriate for NM re-ed in post-acute lateral ankle sprain rehab?
- ladder drills
50
What is a primary consideration for WB in the acute phase of lateral ankle sprain rehab?
- make sure it's supported
51
Is early WB in the acute phase of lateral ankle sprain appropriate? What level of evidence?
- yes; supported w/ AD
| - Grade A
52
Are bracing/casting appropriate for acute lateral ankle sprain?
- yes
53
Is taping an appropriate intervention for acute lateral ankle sprain?
- yes
54
What are two types of taping for acute lateral ankle sprain?
- open-basket weave
| - lateral ankle support
55
What are the recommendations and grades of evidence for acute lateral ankle sprain with the following modalities:
- Cryotherapy
- Ultrasound
- Electrotherapy
- Short wave diathermy
- low-level laser
o Cryotherapy (A; use!) /therapeutic ultrasound (A; don’t use!)
o Electrotherapy/low-level laser therapy (D)
o Shortwave diathermy (C)
56
Is manual therapy appropriate for heel pain/plantar fasciitis management? What grade of evidence?
- yes
| - Grade A
57
What primary impairments are targeted with manual therapy for heel pain/plantar fasciitis?
- joint mobility deficits
- calf flexibility deficits
- pain
58
What are often the targets for STM for heel pain or plantar fasciitis? (3)
- gastroc
- soleus
- flexor hallicus longus
- targeted as they are involved
59
What are often the primary targets for joint mobilizations for heel pain/plantar fasciitis? (3)
- talocrural joint mobs
- sub talar medial/lateral glides (in sidelying)
- cuboid, navicular, cuneiform manips
60
Is stretching appropriate for heel pain/plantar fasciitis management? What grade evidence?
- yes
| - Grade A
61
What are the benefits for stretching for plantar fasciitis/heel pain management? What structures are targeted?
- pain reduction
| - gastroc, soleus, plantar fascia
62
When is stretching most beneficial for plantar fasciitis/heel pain?
- first 2-4 weeks
63
What movements create a plantar fascia stretch?
- dorsiflexion with eversion and GT DF
64
How often should plantar fascia stretching occur for management of plantar fasciitis? How long for the holds?
- throughout the day every couple of hours
| - for at least 10 seconds
65
Is strengthening or movement training appropriate for heel pain/plantar fasciitis? What grade evidence? What would be the goal?
- it's fine to do, but there's no literature behind it
- Grade F
- improve strength of musculature that controls pronation and attenuates forces during WB
66
Is open-chain therex appropriate for strengthening for heel pain/plantar fasciitis?
- sure, but doesn't seem like it's in favor per medbridge. If able to do WB/closed-chain therex, select that option on the test
67
Is taping appropriate for heel pain/plantar fasciitis?
What grade of evidence?
- yes
| - Grade A
68
What two types of taping are appropriate for management of heel pain/plantar fasciitis?
What are their differences?
- anti-pronation (low-dye)
- stiffer tape
- impacts pain and function for up to 3 weeks
- elastic taping to plantar fascia or gastroc
- only helps with pain reduction
- gastroc taping only effective for ~1 week
Overall a short-term effect primarily on pain
69
Are foot orthoses appropriate for heel pain/plantar fasciitis? What grade evidence?
- Yes, people should use them
| - Grade A
70
Is there a difference between pre-fab or custom orthotics in pt w/ plantar fasciitis?
- nope, not really
71
What is predictive of people who are more likely to benefit from orthoses for heel pain/plantar fasciitis management?
- people who respond positively to anti-pronation taping
72
What are the two primary characteristics of orthotics for heel pain/plantar fasciitis?
- support for medial longitudinal arch
| - heel cushion
73
Are the effects for orthotics for heel pain/plantar fasciitis short term, long term, or both?
- both
74
Are night splints appropriate for heel pain/plantar fasciitis? What grade evidence?
- yes
| - Grade A
75
How long are night splints typically used to provide a benefit for heel pain/plantar fasciitis?
- 1-3 months
| - should be seeing an effect from them within that timeframe
76
What is predictive of people who are likely to benefit from night splints for plantar fasciitis management?
- first step pain in the morning
77
T or F;
Night splints can be a stand-alone intervention for plantar fasciitis.
- F-ish. I mean, they can be, but much more effective as something used in conjunction w/ orthoses, taping, stretching, NSAIDs
78
Is there a difference in efficacy for different types of night splints?
- nope, not really. But most people sleep better with a posterior construction than an anterior one
79
What are the recommendations and grades of evidence for heel pain/plantar fasciitis with the following modalities:
- Electrotherapy
- Low level laser
- Phonophoresis
- Ultrasound
- Electrotherapy
- Grade D
- can be used in conjunction with other things
- Low level laser
- Grade C
- may be used to help pain; no physiological changes noted
- Phonophoresis
- Grade D
- Ketoprofen is commonly used if this is done; can be done
- Ultrasound
- Grade C; don't do it
- Cannot be recommended for plantar fasciitis/heel pain
80
Are certain footwear recommended for heel pain/plantar fasciitis? What grade of evidence?
- shoe rotation during work week and rocker bottom shoes w/ foot orthoses can be recommended
- overall Grade D
81
Is dry needling recommended for heel pain/plantar fasciitis? What grade evidence?
- cannot be recommended
| - Grade F
82
What type of therex is recommended for heel pain/plantar fasciitis?
- arch raise progressions and integration into WB/dynamic movement
83
Is corticosteroid injection recommended for plantar fasciitis/heel pain management?
- No
- level I evidence against it's use due to risk of plantar fascia rupture (~11%)
- benefit doesn't outweigh risk
84
Is shockwave therapy appropriate for plantar fasciitis management?
- conflicting evidence...so I'm not going to do it
85
T or F;
Plantar fasciitis is the most common foot condition seen in most clinics
- T
| - ~ 15% of all foot complaints in adults are accompanied by plantar fasciitis
86
What are the 3 most commonly reported foot pathologies in athletic populations?
- achilles tendionopathy
- plantar fasciitis
- stress fx
87
T or F;
There are pathoanatomical changes in the plantar fascia that accompany plantar fascitis?
- T
| - increased plantar fascia thickness is associated with symptoms
88
What is the strongest single contributor to disability with general foot/ankle conditions?
- Pain-related fear of movement
89
What is the typical duration of symptoms with heel pain/plantar fasciitis?
- 13-14 months
90
What % of patients have improvement plantar fasciitis/heel pain symptoms at 1 year follow up?
- 80%
91
What are two Grade B risk factors for development of plantar fasciitis/heel pain?
- limited DF
| - high BMI (nonathletic populations)
92
What are risk factors of plantar fasciitis/heel pain? (6)
- limited DF
- high BMI
- work related WB activity
- running
- high arch type
- leg length discrepancy
93
What are 5 primary diagnostic indicators of plantar fasciitis? (Grade B)
- first step pain
- pain with prolonged weight bearing
- precipitated by an increased volume of weight bearing
- positive windlass test
- negative tarsal tunnel test
- pain with palpation of proximal attachment
94
The windlass test has high specificity and low sensitivity? Or the opposite?
- high specificity and low sensitivity
95
Per the FPI-6, is a more pronated or supinated foot posture associated with chronic heel plantar pain?
- more pronated
96
What are 4 primary differential diagnosis considerations for plantar fasciitis?
- Tarsal tunnel syndrome
- fat pad atrophy
- spondyloarthritis
- plantar fibroma
97
A retrospective study showed that ___% of plantar heel pain patients were diagnosed with fat pad atrophy.
15%
98
Plantar heel pain is reported in ___% of patients with spondyloarthritis, with ____% reporting it as the first symptom
47% of spondyloarthritis patients had plantar heel pain, with 15% having it as the first symptom
99
What are appropriate outocome measures for pts with plantar heel pain/plantar fasciitis?
- FAAM
- VAS
- NRS
- FPI-6
100
What is mechanically occurring in Tarsal Tunnel Syndrome?
- compression of the posterior tibial nerve by the flexor retinaculum
101
What symptoms are characteristics of Tarsal Tunnel Syndrome?
- burning type pain in the medial arch and ball of the foot
102
Baxter's nerve entrapment involves which nerve? What is characteristic of it?
- lateral plantar nerve
| - burning type pain in weight bearing
103
How much first MTP extension is required for pre-swing phase of gait?
- at least 65*
104
How much eversion ROM should be occurring at loading response? What joints need appropriate mobility to achieve the eversion?
- 4-6* of eversion
| - talocalcaneal
105
What muscles primarily help control the rate and extent of pronation?
- tibialis posterior and fibularis longus (peroneus longus)
106
How much DF is required at terminal stance for normal mechanics?
- 10*
107
What musculature restrains tibial progression during ankle DF?
- gastroc
108
Is hamstring tightness associated with heel pain?
- yes; 9x more likely if hamstring tightness
109
How much ROM do you want in a SLR to avoid increased risk for heel pain?
- 75* or >; hamstring length
110
Is education recommended for plantar fasciitis?
- yes; in conjunction with everything else
111
What proximal limitations may be addressed to reduce loading on the plantar fascia?
- reducing hip ER tightness
112
In general, are modalities recommended for plantar fasciitis management?
- no
